Mamawasis (waiting houses) for safe motherhood in rural Peru

Peru, the third largest country by area in South America, deserves notice for the enormous strides it has made to ensure that more children there survive past the age of five. From 1990 to 2007, the country’s under-five mortality rate dropped by 74 per cent – the fastest rate of decline in the entire Latin American and Caribbean region for that period. However, Peru is not faring as well in maternal mortality indicators. In 2008, it was among eight countries added to the Countdown to 2015 list of priority countries under the criteria of high maternal mortality ratio and numbers of maternal deaths. According to international estimates, Peru’s maternal mortality ratio is 240 per 100,000 live births. This national average masks disparities in the health outcomes of different population groups in the country. The pregnant women and mothers most at risk of being excluded from quality health services are largely from rural indigenous communities in the Peruvian Amazon and the Andean sierra.

One of the main determinants of maternal morbidity and mortality is the presence of skilled attendants at birth. Yet, estimates from 2003 to 2006 show that this critical service was lacking where it was needed most; in the poorest quintile of the Peruvian population, skilled attendants were present at only 35 per cent of births.

There is also a yawning gap in access to maternal health services between rural and urban zones. According to the Ministry of Health, women in rural areas are twice as likely as those in urban areas to die from causes related to pregnancy. In 2000, skilled attendants reached only 20 per cent of women at delivery in rural communities, compared with 69 per cent of women in urban areas.

Distance and transportation costs from their homes to health centres impede some rural women from delivering their babies in health facilities, and a cultural preference for home delivery instead of institutional delivery prevails in many rural households. Traditional birthing practices among many rural indigenous communities include giving birth in a squatting position in a darkened room of the house, assisted by a traditional birth attendant and family members. The room is also warmed by a smoky fire and the pregnant woman is encouraged to drink plenty of herbal tea. This birthing experience contrasts starkly with one in which a stranger presides over the birth in a brightly lit delivery room in a health centre.

Unfortunately, home delivery can heighten the risks to the lives of mothers and newborns, especially when emergency obstetric care is required, warning signs are not recognized and there is a delay in deciding to seek care and getting to a health centre.

Since 1998, Peru’s Ministry of Health – together with its partners – has developed the following fourfold strategy to address the geographical, cultural and economic barriers that limit women’s access to facility-based care:

Mamawasis encourage women who might otherwise be deterred by distance to give birth in facilities rather than at home. Usually located in health centres, on hospital grounds or in rented buildings nearby, they invite pregnant women and their families to stay for a few weeks to ensure that, at the time of delivery, the mother is in close proximity to a health centre. After the birth, both mother and newborn move from the health centre to the mamawasi so that their well-being can be monitored. Community participation is critical to the smooth functioning of the mamawasis, especially in linking health-centre workers with pregnant women. To date, there are around 390 mamawasis in the southern Andean regions of Cuzco, Apurímac and Ayacucho. In a further bid to culturally sensitize delivery of services for maternal health, health centres across the country are allowing women to give birth in an upright position and offering a more homely ambience.

As a result of the Government’s policy of promoting cultural sensitivity in health care, rates of institutional delivery across rural Peru have risen significantly. Huancarani district, located in the Andean province of Paucartambo in the Cuzco region, has been most successful in implementing the new strategy. Here, almost three out of every four pregnant women now visits health-care centres, especially for childbirth, whereas previously it was one in four. In 2004, the Ministry of Health adopted the policy of transforming maternal health services to suit rural cultural preferences as a national standard. The government has also created training modules to teach health personnel how to make services culturally appropriate.